Global, regional, and national burdens of atrial fibrillation/flutter from 1990 to 2019: An age-period-cohort analysis using the Global Burden of Disease 2019 study

Abstract

Background: Atrial fibrillation/flutter (AF/AFL) significantly impacts countries with varying income levels. We aimed to present worldwide estimates of its burden from 1990 to 2019 using data from the Global Burden of Disease (GBD) study.

Methods: We derived cause-specific AF/AFL mortality and disability-adjusted life-year (DALY) estimates from the GBD 2019 study data. We used an age-period-cohort (APC) model to predict annual changes in mortality (net drifts), annual percentage changes from 50-55 to 90-95 years (local drifts), and period and cohort relative risks (period and cohort effects) between 1990 and 2019 by sex and sociodemographic index (SDI) quintiles. This allowed us to determine the impacts of age, period, and cohort on mortality and DALY trends and the inequities and treatment gaps in AF/AFL management.

Results: Based on GBD data, our estimates showed that 59.7 million cases of AF/AFL occurred worldwide in 2019, while the number of AF/AFL deaths rose from 117 000 to 315 000 (61.5% women). All-age mortality and DALYs increased considerably from 1990 to 2019, and there was an increase in age risk and a shift in death and DALYs toward the older (>80) population. Although the global net drift mortality of AF/AFL decreased overall (-0.16%; 95% confidence interval (CI) = -0.20, 0.12 per year), we observed an opposite trend in the low-middle SDI (0.53%; 95% CI = 0.44, 0.63) and low SDI regions (0.32%; 95% CI = 0.18, 0.45). Compared with net drift among men (-0.08%; 95% CI = -0.14, -0.02), women had a greater downward trend or smaller upward trend of AF/AFL (-0.21%; 95% CI = -0.26, -0.16) in mortality in middle- and low-middle-SDI countries (P < 0.001). Uzbekistan had the largest net drift of mortality (4.21%; 95% CI = 3.51, 4.9) and DALYs (2.16%; 95% CI = 2.05, 2.27) among all countries. High body mass index, high blood pressure, smoking, and alcohol consumption were more prevalent in developed countries; nevertheless, lead exposure was more prominent in developing countries and regions.

Conclusions: The burden of AF/AFL in 2019 and its temporal evolution from 1990 to 2019 differed significantly across SDI quintiles, sexes, geographic locations, and countries, necessitating the prioritisation of health policies based on risk-differentiated, cost-effective AF/AFL management.

Figure 1

Age-standardised mortality. Panel A. Percentage change in mortality. Panel B. Rates of atrial fibrillation/atrial flutter across 204 countries and territories from 1990 to 2019. In this figure, the ASR and percentage change in ASR in North America all increased. This result may be due to the high overall life expectancy of the population in the region and the high burden of disease as a result of the region's aging population. ASR – age-standard mortality rate.

Figure 2

Local drifts of AF/AFL mortality and age distribution of death from AF/AFL by SDI quintiles, 1990-2019. Panel A. Local drifts of AF/AFL mortality (estimates from age-period-cohort models) for nine age groups (50-54 to 90-95 years), 1990-2019. Panel B. Temporal change in the relative proportion of AF/AFL deaths across age groups (0-49, 50-59, 60-69, 70-79, 80-89, >90 years), 1990-2019. AF/AFL – atrial fibrillation/atrial flutter. SDI – sociodemographic index.

Figure 3

Age, period and cohort effects on AF/AFL mortality by SDI quintiles. Panel A. Age effects are shown by the fitted longitudinal age curves of mortality (per 100 000 person-years) adjusted for period deviations. Panel B. Period effects are shown by the relative risk of mortality (mortality rate ratio) and computed as the ratio of age-specific rates from 1990 to 1994 to 2015-2019 (the referent period, 2000-2004). Panel C. Cohort effects are shown by the relative risk of mortality and computed as the ratio of age-specific rates from the 1895 cohort to the 1965 cohort, with the reference cohort set at 1930. We presented the mortality rates or rate ratios and their corresponding 95% CIs. AF/AFL – atrial fibrillation/atrial flutter, SDI – sociodemographic index.

Figure 4

Age distribution of AF/AFL death and age-period-cohort effects on exemplar countries across SDI quintiles. AF/AFL – atrial fibrillation/atrial flutter, SDI – sociodemographic index.

Figure 5

Major risk factors for age-standardised death of AF/AFL across SDI quintiles, 1990-2019. AF/AFL – atrial fibrillation/atrial flutter, SDI – sociodemographic index.